Chapter 13
Interventions to Prevent Elder Mistreatment
Karl A. Pillemer, Katrin U. Mueller-Johnson, Steven E. Mock, J. Jill Suitor, and Mark S. Lachs
13.1. BACKGROUND AND INTRODUCTION
Over the past two decades, increasing attention has been paid to mistreatment of older persons by researchers, policy makers, and the general public. In this chapter, we review issues related to the prevention of elder abuse and neglect. We begin by discussing the state of existing research and estimates of the extent of the problem. We provide a discussion of risk factors, because prevention programs necessarily need to take probable risk factors into account. We then review types of interventions that have been used to prevent elder abuse. As will be discussed, there is a paucity of reliable research on elder abuse in general and almost no scientifically acceptable research on the effectiveness of various prevention strate- gies for elder mistreatment. For this reason, we focus on identifying promising program examples and on suggestions for future research. Further, several preven- tive options are controversial in the field of elder abuse and, therefore, require rigorous evaluation.
13.1.1. Definitions
A recent panel convened by the U.S. National Academy of Sciences (National Research Council, 2002) has proposed a useful scientific vocabulary for elder mis- treatment, which we follow in this chapter. Elder abuse is defined as: “(a) inten- tional actions that cause harm or create a serious risk of harm (whether or not harm is intended), to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or (b) failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm.” This definition encompasses two key ideas: that the older individual has suffered injury, deprivation, or unnecessary
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danger and that a specific other person (or persons) is responsible for causing or failing to prevent it.
Within the overarching framework of elder abuse, there is now general agree- ment on the scope of actions that fall under this rubric. Researchers, practitioners, and most legal statutes recognize the following types of abuse: (1) physical abuse, which includes acts carried out with the intention to cause physical pain or injury;
(2) psychological abuse, defined as acts carried out with the intention of causing emotional pain or injury; (3) sexual assault; (4) material exploitation, involving the misappropriation of the elder’s money or property, and (5) neglect, or the failure of a designated caregiver to meet the needs of a dependent older person.
For the purposes of this chapter, we focus primarily on physical abuse, because of its clear relationship to the potential for injury. However, a number of studies and prevention programs focus on one or more additional types of abuse, and we have included them in our discussion.
13.1.2. Problems in the Research Base
Before summarizing the available findings, it is important to review briefly the prob- lems in using existing research to understand risk factors for elder mistreatment and the potential effectiveness of prevention programs. The first major limitation of previous research is an unclear definition of the object of study. Most studies are weakened by their undifferentiated treatment of various types of abuse and neglect. Second, different criteria have been used to determine the population at risk of elder mistreatment. Some researchers have included people younger than 60 years of age in their studies, whereas most others have chosen 60 or 65 years as the entry point. A number of investigators have restricted their studies to caregivers to elderly people, frail elders, or to people sharing a residence, while others have included all categories of older people.
Third, few studies that have purported to address risk factors have in fact included comparison groups in their designs. For this reason, the generalizations made by the researchers are necessarily suspect. Fourth, studies have employed widely differing methods, including random sample surveys, interviews with patients in medical practices or caregivers in support programs, and reviews of agency records. Fifth, a number of studies have not employed reliable and valid measure- ment of the indicators of risk.
Sixth, with one exception (Lachs, Berkman, Fulmer, & Horwitz, 1994; Lachs, Williams, O’Brien, Hurst, & Horowitz, 1997), prospective studies of elder abuse do not exist. As Lachs et al. (1994) point out, retrospective research designs contain several potential biases, including recall bias, the respondent reinterpreting key facts or feelings from a later vantage point; information bias, the respondent (espe- cially if cognitively impaired) may not be able to recall or provide valid information about exposure to maltreatment; and the failure of retrospective studies to take into account the timing and duration of events and their progression over time.
Finally, and most pertinent to this chapter, there is little hard evidence regard- ing the effects of interventions of any kind, including preventive interventions.
A review of the elder abuse literature for the period 1980–1996 by the National Academy of Sciences Committee on Family Violence Interventions (Chalk & King, 1998) produced reports on approximately a dozen elder abuse programs. Seven of these were evaluation studies that included outcome measures, but only two met the scientific standard for inclusion in the evidentiary base for the committee’s report. Both of the latter were small-scale projects: one assigned advocates to
elder victims to help them navigate the criminal justice system; the second offered stress-management and self-esteem training to potential victims. The others lacked random assignment or the sample size was too small for meaningful comparisons.
Unfortunately, the intervening years have uncovered only a few additional inter- vention studies that used scientifically acceptable methods (discussed later in this chapter).
13.1.3. Extent of Elder Abuse
To justify expending resources for prevention programs, the question of the size and scope of a problem must be addressed: Is elder abuse sufficiently extensive to justify investment in prevention programs? Evidence is available from four large- scale population surveys that have been conducted to date. Pillemer and Finkel- hor (1988), in a probability sample of noninstitutionalized elders in the Boston, Massachusetts, metropolitan area, found an overall prevalence rate of 3.2%. A national random sample survey of elderly persons in Canada used similar methods and uncovered a rate of 4% reporting having experienced maltreatment since turning 65 (Podnieks, 1992). The difference in rate may be explained by the fact that the U.S. survey assessed physical abuse, psychological abuse, and neglect, whereas the Canadian survey included material abuse in addition to these categories. A Dutch study (Comijs, Penninx, Knipscheer, & van Tilberg, 1999), which included these four types of abuse, found a 1-year prevalence rate of 5.8%. Researchers in Scandinavia conducted a telephone survey of national samples from Denmark and Sweden but used more inclusive definitions of elder abuse (including theft). This study found a prevalence of 8%, but the higher rate is driven by the inclusion of theft as a type of abuse (Tornstam, 1989).
These results suggest that the extent of elder abuse is sufficiently large that social service and health professionals who serve older adults are likely to encounter it on a routine basis. Indeed, elder abuse is prevalent enough to be encountered in daily clinical practice with regularity. For example, using the prevalence rates just described, a clinician seeing between 20 and 40 older adults a day could encounter at least one clinical or subclinical victim of elder abuse daily (Lachs & Pillemer, 2004). Further, as our discussion of risk factors below shows, some subpopulations that are overrepresented in the elder service system (such as people with dementia) have higher risk of abuse. Thus prevention programs appear to be well justified for this population.
13.1.4. Risk Factors for Elder Mistreatment
The development of effective prevention programs is predicated on an understand- ing of risk factors for mistreatment. Because of the problems in the research base discussed earlier, it must be acknowledged that any statements about relative risk among the elderly must be viewed with caution. However, the small number of studies using acceptable research designs does reveal some patterns of potential risk factors, as follows (Lachs & Pillemer, 2004).
13.1.4.1. Living Arrangement
Both clinical accounts and limited empirical research suggest that a shared living situation is a major risk factor for elder mistreatment; older people who live alone are at the lowest risk (Lachs et al., 1997; Paveza et al., 1992; Pillemer & Finkelhor,
1988; Pillemer & Suitor, 1992). A shared residence increases the opportunities for contact, and thus conflict and mistreatment. Further, tensions that might be relieved by simply leaving the immediate situation can escalate into maltreatment (Wolf and Pillemer, 1989).
13.1.4.2. Social Isolation
Social isolation has been found to be characteristic of families in which other forms of domestic violence occur. Research on elder abuse provides support for this view.
In Lachs et al.’s (1994) prospective, community-based study of risk factors for elder abuse, having a “poor social network” significantly increased risk of mistreatment.
Findings from a number of other studies indicate that victims and abusive relatives have lower levels of social support (Compton, Flanagan, & Gregg, 1997; Grafstrom, Nordberg, & Windblad, 1993; Phillips, 1983; Wolf & Pillemer, 1989).
13.1.4.3. Dementia
There is evidence suggesting that dementia places elderly persons at greater risk of mistreatment. Several studies have attempted to determine prevalence rates of elder mistreatment in samples of dementia caregivers; these rates can then be com- pared to rates in general population surveys. Coyne, Reichman, & Berbig (1993) found that 11.9% of the dementia caregivers in their sample reported having com- mitted physical abuse. Paveza et al. (1992) found a rate of severe physical violence toward care recipients of 5.4%, which is close to Pillemer and Suitor’s (1992) finding of 5% in a similar sample. Homer and Gilleard (1990) found physical abuse occurring in 14% of caregivers to Alzheimer’s disease (AD) patients in a respite care program. Given the prevalence findings of rates of physical abuse in the 1–3%
range, dementia patients would appear to be at greater risk of such mistreatment.
It should be noted that it is possible that caregivers may be more likely to report mistreatment than older persons themselves, leading to an inflation of the rates among demented individuals. However, in a longitudinal panel study that did not relay on caregiver interviews, Lachs et al. (1997) found that dementia predicted identification as an abuse victim.
13.1.4.4. Psychological Problems and Substance Abuse
A history of mental illness has been found to characterize elder abusers (Pillemer
& Finkelhor, 1989; Reis & Nahmiash, 1998; Wolf & Pillemer, 1988). Several studies have specifically pointed to depression as characteristic of perpetrators of elder mistreatment (Coyne et al., 1993; Fulmer, 1991; Homer & Gilleard, 1990; Paveza et al., 1992; Reay Campbell & Browne, 2002; Williamson & Shaffer, 2001). Sub- stance misuse on the part of family members also is related to elder abuse. Indeed, studies of elder mistreatment suggest that alcohol abuse on the part of perpetra- tors is a disproportionately common occurrence (Anetzberger, Korbin, & Austin, 1994; Bristowe & Collins, 1989; Greenberg, McKibben, & Raymond, 1990; Homer &
Gilleard, 1990; Reay Campbell & Browne, 2002; Wolf & Pillemer, 1989).
13.1.4.5. Abuser Dependency
Related to the previous risk factor, findings from research on elder mistreatment suggested that perpetrators tend to be dependent on the individual they are mis-
treating (Anetzberger, 1987; Greenberg et al., 1990; Pillemer, 1986, 2004; Pillemer
& Finkelhor, 1989; Wolf & Pillemer, 1989; Wolf, Strugnell, & Godkin, 1982).
13.1.4.6. Health and Functional Status
The role of victim health and functional status as a risk factor in elder abuse is complex. Although anecdotal and clinical reports have long suggested that the frailty of elderly persons in itself is a risk factor for abuse, studies have generally failed to find a direct relationship between elder abuse and victims’ poor health or functional impairment (Bristowe & Collins, 1989; Cooney & Mortimer, 1995;
Paveza et al., 1992; Phillips 1983) or excessive dependency on the abuser (Bristowe
& Collins, 1989; Homer & Gilleard, 1990; Phillips, 1983; Pillemer, 1985; Pillemer &
Finkelhor, 1989; Pillemer & Suitor, 1992; Reis & Nahmiash, 1997; Wolf & Pillemer, 1989). Nonetheless, it is likely that increased frailty in the elder does play at least some role in abuse. Rather than increasing risk in and of itself, greater impairment may diminish the individual’s ability to defend himself or herself or to escape the situation. Further, impairment may increase social isolation, and thus raise risk for elder abuse. It seems reasonable to consider physical health problems as a predisposing factor in elder maltreatment, which may increase vulnerability in the presence of risk other factors.
A variety of other potential risk factors are discussed in the literature, but reliable scientific evidence regarding them is lacking. Potential but unsubstanti- ated factors include caregiver stress and burden and the intergenerational trans- mission of violent behavior (i.e., abuse experienced as a child). Relative risk that results from race, gender, or relationship to the abuser (spouse or adult child) is inconclusive.
13.2. ELDER ABUSE PREVENTION PROGRAMS: THE STATE OF THE ART
In the remainder of this chapter, we discuss a variety of interventions that may have the potential to prevent elder abuse. We do so with the caution, however, that not only are evaluation data typically lacking on the options but well-documented practical experience is also limited in most cases. The analysis here must, therefore, be seen as speculative. Indeed, as we discuss in the concluding section, rigorously conducted intervention studies are greatly needed to determine the most effective elder abuse prevention strategies.
13.2.1. Screening
A considerable literature exists on screening programs for elder abuse. The premise behind such programs is that predicting the possibility of abusive practices allows for intervention before maltreatment occurs. Screening programs often use inter- views and/or direct observation of older persons (and sometimes family members) to identify potentially abusive situations. A few elder abuse screening instruments have been validated in preliminary ways (Fulmer, Guadano, Dyer, & Connolly, 2004;
Reis & Nahmiash, 1998; Schofield & Mishra, 2003). The intuitive appeal of screen- ing instruments and programs is clear: elder abuse victims may “suffer in silence”
until the problem is brought to light by a health or social service professional.
In general, existing screening protocols suffer from methodological problems in their construction and validation, which derive largely from the special nature of elder abuse and its difference from medical problems typically addressed by screening. Specifically, in the traditional medical model of screening, an indi- vidual who wishes early detection of a prevalent disease (e.g., diabetes, high blood pressure) presents asymptomatically for a minimally invasive test. Further, typically a definitive gold standard test exists to confirm or refute the findings of a posi- tive screening test. This situation, however, has limited applicability to elder abuse (Lachs & Pillemer, 2004). Victims may be frail and socially isolated, cognitively impaired, and not receptive to additional investigation or treatment. They may be accompanied to the screening venue (e.g., a doctor’s office) by the abuser.
Unlike the “worried well” individual who wishes detection of an early disease, the elder abuse victim may actively seek to hide its manifestations from a screening professional.
Even more compellingly, there is no universally agreed-on gold standard test as to what constitutes definitive elder abuse, so verification of the screen is diffi - cult. Thus the potential for both false positives and false negatives exists to a much greater degree than with screening for other types of problems. For example, injuries could be a sign of elder abuse but are more often sustained through falls or other accidents. Weight loss might result from the intentional withholding of food or care but is equally or more likely caused by other factors such as cancer or chronic disease.
In sum, given the state of the art, wide-scale screening does not appear to have significant potential for elder abuse prevention at present. The threat to both sensitivity and specificity are great—that is, screening instruments’ accuracy in identifying high-risk subjects on the one hand, and in correctly exempting low-risk subjects on the other. A compelling reason for caution thus exists. If screening is carried out with unvalidated instruments, the reliability of which is unknown, then risks to older people may result. In particular, if the screen incorrectly identifies an older person as being at risk, he or she may be subject to an invasive investigation and to possible stigmatization as an “abused elder.” Thus, although early identifica- tion of elder abuse victims is clearly desirable, it is prudent to await more definitive research findings before promoting screening programs on a wide scale.
Given these caveats, how should we proceed in this area? Fulmer and O’Malley (1987) proposed a reasonable solution that has been supported by more recent discussions. They suggest that the best role for screening instruments is to heighten professional awareness of the possibility of elder abuse and to alert clinicians to signs and symptoms that might otherwise be missed. Lachs and Pillemer (2004) concur that the best policy at this time, rather than overreliance on a specific screening strategy or clinical algorithm, is education to raise awareness of elder abuse in clinicians. Incorporation of training on the general detection of elder abuse (rather than reliance on a specific screening instrument) into medical and other relevant professional education should be a high priority.
13.2.2. Mandatory Reporting
Most states have laws that specifically mandate the reporting of elder abuse, although the statutes differ considerably in terms of definitions of mistreatment, population covered, sanctions for not reporting, and other aspects. Mandatory reporting is seen by proponents as having an important tertiary prevention component. That is,
by bringing cases of elder abuse to the attention of an agency, services can be initi- ated that prevent revictimization. Further, it is claimed that mandatory reporting laws serve to increase public awareness of the problem of elder abuse and prompt service providers to be on the lookout for suspected maltreatment. In contrast, opponents argue that there is no evidence that mandatory reporting is effective.
Critics note that states have failed to provide sufficient funds for services to victims and abusers, and limited staff must attempt to handle a large number of referrals in response to the law. Others claim that reporting interferes with the relationship and confidentiality between the professionals and clients.
Under mandatory reporting legislation, professionals are faced with a dilemma:
either to violate the law or break trust with a client and possibly jeopardize a thera- peutic relationship. Critics maintain that by extending a child abuse model to the elderly, a set of assumptions has been adopted that are not applicable to older people. Specifically, they infantilize the elder’s position in society, foster negative stereotypes of the aged, and limit the older people’s abilities to control their own lives. At a minimum, mandatory reporting must be accompanied by a substantial commitment of resources to the designated reporting agency. To date, no sci- entific evidence exists on which to evaluate the costs and benefits of mandatory reporting.
13.2.3. Adult Protective Services
All states offer some form of protective services for elder abuse victims, although there is again significant variation from state to state. If a state protective services program operates under an adult protective service statute, it is generally limited to “incapacitated” adults, leaving other agencies such as the police, legal services, and the criminal justice system to handle situations involving more competent and physically able persons. On the other hand, programs authorized under elder abuse legislation usually apply to any older individual who is at risk of abuse, neglect, or exploitation. Some states restrict their cases to people living in their own homes;
others include group and institutional settings as well.
It is possible that adult protective services may constitute a form of tertiary prevention, helping abused older people escape further victimization and its con- sequences. However, although adult protective services have gained greater vis- ibility and credibility in the past decade, it is a controversial area of service. Some critics see such programs as an intrusion on the civil liberties of the elderly. They also argue that states define abuse too broadly and allow an intrusion into families with merely the normal range of human problems. States have responded to such criticisms by emphasizing that the client’s right to self-determination is one of the basic principles of protective services (Wolf & Pillemer, 1989).
Despite the fact that hundreds of thousands of cases have been investigated and millions of dollars spent by protective services, evaluation data are sorely lacking. This is somewhat troubling in light of the only two studies that have attempted to examine the effect of elder protective services. Both studies found a negative effect of protective services intervention for older persons; protective service clients are more likely to be placed in nursing homes than nonclients and to experience greater mortality (Blenkner, 1971; Lachs, Williams, O’Brien, &
Pillemer, 2002; Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998). Because of the possibility of this type of unanticipated negative effect, evaluation of the effect of elder protective services is greatly needed.
13.2.4. Education of Professionals
Over the past two decades, a wide variety of educational and training programs has been developed, targeted at virtually every profession that encounters older people, including physicians (Ahmad & Lachs, 2002; Lachs & Pillemer, 2004), nurses (Bond, 2004; Richardson, Kitchen, & Livingston, 2002), and social workers (Richardson et al., 2002; Wilke & Vinton, 2003). In theory, such programs may help professionals detect elder abuse by increasing their awareness of potential signs and symptoms. Little evidence exists as to whether such programs are effective in raising professional awareness, although two studies indicate that professional education did increase knowledge about elder abuse compared to control groups (Anetzberger et al., 2000; Richardson et al., 2002). No studies have been conducted regarding whether education of professionals leads to outcomes of any kind for victims, including prevention.
13.2.5. Caregiver Support Interventions
Another approach to elder abuse prevention has been based on the assumption that dependency of the victim and resulting caregiver stress is a major cause of mal- treatment. Prevention programs based on this paradigm have taken several forms.
Some communities and agencies have emphasized health and social services for the elderly that are not specific to abuse. In many cases, services to relieve the burden of caregiving, such as housekeeping and meal preparation, respite care, support groups, and day care are promoted as abuse-prevention strategies.
Such programs are undoubtedly useful for the primary purpose for which they are intended: improving older persons’ functioning and reducing caregiver burden and distress. In fact, preliminary evidence from two recent studies suggests that an intervention targeted toward abusive caregivers may help prevent revictim- ization (Nahmiash & Reis, 2000; Reay Campbell & Browne, 2002). However, the research discussed earlier indicates that caregiver stress and elder dependency are causal factors in only a small number of cases (in the absence of other risk factors such as mental illness or substance abuse on the part of the caregiver). Therefore, caregiver stress—oriented interventions may have preventive potential in only a limited subset of cases.
13.2.6. Education of Potential Victims
Adult protective services and other intervention programs report the lack of self- referral from victims, who are often ashamed to admit family problems and are unaware that services may exist to help them. Public-awareness campaigns directed toward older people may encourage victims to report abuse in its early stages (or to seek help before a tense family situation erupts into abuse) and thus serve a preventive function. A currently ongoing public awareness campaign in Vermont, for instance, includes the placement of flyers with information about elder abuse in prescription bags in pharmacies and stickers on Meals on Wheels containers and distributes brochures to senior centers, congregate meal sites, and doctors’ offices (Vermont Center for Crime Victim Services, 2003).
Potential abusers could also be targeted for information, encouraging them to seek help if they fear becoming abusive (or are actually engaging in abusive behaviors). Television and radio spots, newspaper ads, and posters are some of the
avenues currently used in such campaigns to reach the public, including potential abusers (California Attorney General’s Crime and Violence Prevention Center, 2003, Vermont Center for Crime Victim Services, 2003). Although such programs appear promising, no evaluation data as yet exist.
13.2.7. Legal and Victim Advocacy Services
The findings that many elders are abused by a dependent relative suggest that maltreated older persons may benefit from interventions found to be effective with victims of partner abuse. Options for the elderly that relate to the partner abuse model include social support for the older person, employing the use of self- help groups that contribute to consciousness-raising, “safe houses” or emergency shelters, and legal action. Although individual examples of these programs exist, no evaluation data regarding their effectiveness are available.
One type of intervention derived from the partner abuse model is law enforce- ment involvement in cases of elder mistreatment. A single controlled study has been conducted, with unexpected results. Davis and Medina-Ariza (2001) used a randomized controlled experiment to evaluate a program that involved home visits by a team of a police officer and a domestic violence counselor to known elder abuse victims, in an effort to reduce revictimization. Those individuals who received a home visit, however, reported more physical abuse at follow-up than did the controls. The authors speculated that the increase in violence after the home visits could have occurred because the home visits angered the perpetrators; but because the perpetrators in the study were not interviewed, this point had to remain conjecture. Clearly, such programs require careful additional evaluation before they can be promoted as prevention strategies.
13.3. CONCLUSIONS AND RECOMMENDATIONS
We have reviewed a variety of preventive options for elder mistreatment in this chapter. A helpful way to organize potential elder mistreatment prevention pro- grams uses a paradigm that identifies universal, selective, and indicated measures (Gordon, 1983; Mrazek and Haggerty, 1994). Universal preventive measures are used for the general public and for all members of potentially affected groups—
in this case, older people. Table 13.1 organizes selected elder abuse prevention options using this prevention model. In the case of elder abuse, universal pre- vention can refer to efforts to increase societal awareness and educate the public about elder mistreatment. Selective prevention is targeted at at-risk populations, either those at risk of becoming victims of elder mistreatment or those at risk of engaging in mistreating behavior. It seeks to prevent mistreatment by directly addressing risk factors, such as caregiver stress, and thus reducing the likelihood that abuse will occur. Indicated prevention is targeted at particularly high-risk individuals. Indicated prevention could take the form of an adult protective service investigation, the separation of the mistreater and the mistreated, or legal proceedings.
As Table 13.1 makes clear, reliable evaluation data clearly do not exist to suggest the relative effectiveness of elder abuse prevention programs; indeed, this field of study is in its infancy. However, the extent of the problem and its potentially serious consequences clearly justify the development of prevention strategies. The
following are several recommendations to advance the field of elder abuse preven- tion, which we believe will help remedy the gaps we have noted in our analysis.
13.3.1. Scientifically Credible Prevention Research Is Greatly Needed Although knowledge regarding probable risk factors has increased over the past two decades, development and evaluation of prevention programs has lagged woe- fully behind. Indeed, only a handful of studies exist that have attempted any form of comparison group design, and these studies suffer from methodological con- cerns that limit generalizability. It is fair to say that we know little more of value regarding elder abuse prevention now than when the problem was “discovered” as a social problem in the 1970s. Professionals who work with older persons struggle against a weak knowledge base and a lack of practical experience in elder abuse prevention.
Table 13.1. Summary of Elder Abuse Prevention Options
Prevention Level Intervention Types Evaluation Status
Universal • Public awareness campaigns (TV • No evaluation data prevention and radio ads, flyers, posters,
community presentations)
• Professional awareness (educational • Higher rates of materials and workshops for awareness of professionals working with older mistreatment adults)
Selective Directed at potential victim
prevention • Screening • No evaluation data
Directed at person at risk of becoming abuser
• Caregiver support interventions • Effective in providing (e.g., stress management, respite support (e.g., reducing
care) stress)
• Caregiver training about dementia • No evaluation data
• Interventions targeted at other • Interventions not yet known risk factors for elder developed, but mistreatment, such as mental- theoretically promising health and substance abuse treatment,
job-skills training, creation of affordable housing
Indicated Directed at potential victim
prevention • Screening • No evaluation data
• Mandatory reporting • No evaluation data
• Adult protective services • Some adverse effects, more evaluation data needed
• Home visitation by police and • Adverse effects social worker
• Social support and self-help groups • No evaluation data
• Safe houses and emergency shelters • No evaluation data Directed at person at risk of becoming abuser
• Mental-health and substance abuse • No evaluation data treatment
• Anger-management training and • Reduction in anger counseling
• Caregiver support interventions • Reduction of revictimization
• Home visitation by police and • Adverse effects social worker
Of particular concern is the possibility that several widely used approaches to prevention and treatment of elder abuse may have unexpected negative conse- quences in some cases. Although data are by no means sufficient on this topic, in this chapter we reviewed concerns regarding screening, mandatory reporting, adult protective services, and law-enforcement options. This evidence, although from a limited number of studies, constitutes perhaps the most compelling argument for additional research—the need to ensure that programs intended to prevent abuse do not in fact have negative effects on those persons they are designed to help.
13.3.2. Multicomponent Interventions Are Needed
It is clear from the review presented here that elder abuse is a complex phenom- enon that has multiple causes. Taken together, the research suggests that physical elder abuse is most likely in situations in which several characteristics are present:
(a) a shared living situation, (2) an older person with some degree of physical vulnerability, (3) a family member who has psychological and/or substance abuse problems, (4) a family member who is to some degree dependent on the victim, and (5) a context of relative social isolation. Each of these risk factors could be addressed individually, but it is likely that a multicomponent prevention interven- tion addressing some or all of these factors will be more effective.
13.3.3. Target Intervention Programs toward Abusers
The risk factor research indicates that prevention programs aimed at abusers may be effective. Indeed, the studies reviewed in this chapter strongly suggest moving from an emphasis on victim characteristics as causes of elder abuse to a focus on perpetrators (Pillemer, 2004). The provision of counseling for the abusive (or potentially abusive) relative could be explored, and the effectiveness of mental health treatment for abusers could be tested to determine if it prevents revictim- ization. A further prevention program could be targeted toward reducing the relative’s dependence on the older person; this might involve aiding the relative in establishing an independent living situation or finding employment (to reduce financial dependency).
13.3.4. Translation of Validated Prevention Programs from Other Fields Should Be Tested for Elder Abuse
To a surprising degree, there has been little translation of successful strategies from other forms of family violence to elder abuse. One of the frequently used universal prevention program for intimate partner violence is public-awareness campaigns, which recently have been adopted for elder abuse prevention, such as in Vermont and California. Evaluations of domestic violence awareness campaigns have shown that they can be effective (Wolfe & Jaffe, 1999). Although evaluation data for the public awareness campaigns targeted at elder abuse are not available at this time, they are feasible and merit testing.
However, direct translation of strategies from other forms of family violence may not be straightforward. As discussed above, one project was modeled on pro- grams that had been successfully employed in reducing younger partner violence (Davis & Medina-Ariza, 2001). This study, which is the only project to include a rig- orous randomized controlled design with victims of elder abuse, resulted in more
reported incidents of abuse than the control group (Davis & Medina-Ariza, 2001).
As the program had been effective with the partner violence sample in the same local area, the negative result in the elder abuse sample was entirely unexpected.
This example shows that translating what works in family violence prevention to the field of elder abuse, although a promising avenue to advance knowledge, can be a highly complicated process.
13.3.5. The Development of Prevention Programs Specifically for Dementia Caregivers Is Warranted
Evidence was reviewed in this chapter regarding the special risk for violence in dementia caregiving relationships. Specifically, severe behavior problems on the part of dementia patients, and in particular physical violence, are related to verbal and physical aggression by caregivers. This pattern of what appears to be retaliative violence appears to hold across settings; a study of abuse by staff in nursing homes found violence by residents to be a major risk factor (Pillemer & Moore, 1989).
Several programs exist to reduce behavioral symptoms among dementia patients;
these strategies should be systematically evaluated for the elder abuse prevention potential. Promising intervention programs for caregivers in general (Anetzberger et al., 2000; Scogin et al., 1992) would benefit greatly from evaluation studies that in addition to measures of the reduction in caregiver stress and anger also included measures of abusive behavior (e.g., from caregiver self-reports or care-recipient reports).
13.3.6. Summary
The available evidence suggests the following points:
• The elder mistreatment research literature does not as yet provide consistent guidelines for prevention programs. Promotion of research on this topic that uses scientifically acceptable designs is critically important to improve prevention practice. Longitudinal studies, case-comparison designs, and carefully controlled intervention studies are particularly needed.
• Elder mistreatment is estimated to affect 2–5% of the older population, suggesting that the magnitude of the problem justifies the development of prevention programs.
• Risk factors for elder mistreatment include living with other persons; social isolation; the presence of dementia; psychological problems, substance abuse, and dependency on the part of perpetrators; and poor health and functional status of victims. Additional research to specify risk factors is greatly needed.
• Commonly used prevention programs—such as screening instruments, mandatory reporting, and adult protective services—have little demon- strated effectiveness for elder mistreatment and may have unanticipated negative consequences. These programs require careful evaluation of both positive and negative outcomes.
• Potentially promising interventions include education of potential victims and professionals and support for caregivers of dementia patients.
Extensive effort is needed to create new and innovative prevention programs.
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